Chapter 5. Partnerships for Meaningful Access

Introduction

This chapter presents several case studies illustrating creative
approaches to widening meaningful access to technology and
resources in diverse and underserved communities. The examples
vary in scope from local to national initiatives, encompassing
both health-specific and more general purposes. The programs
either already serve as channels for e-health tools or represent
potential channels. These examples illustrate ways to address
diverse user characteristics and meaningful access issues described
in Chapter 2. They also show the
effective use of multiple forms of partnership and collaboration
discussed in Chapter 4. The strategies
profiled here rely on not-for-profit ventures supported by
governmental bodies and public interest organizations. Having
proven effective in communities outside the digital and economic
mainstream, these strategies can complement more standard market
approaches. In some cases, they may help create the conditions
for a return on investment in health information technology
in underdeveloped markets.

The present study confirmed earlier findings that many public
and private programs are providing computers and Internet access
for segments of the U.S. population that otherwise might not
have them (HHS, 2003). However,
one of many challenges for those working for equality of opportunity
in this area is that although need and gaps can be documented,
the data for tracking the progress in meeting the need are
limited. This study found that few publicly supported or nonprofit
programs have the resources to document the effect of technology
access on the intended beneficiaries. Even less is known about
user demand for particular content and applications—for
example, what might be of greatest interest to diverse user
groups in supporting personal health management. This is an
important area for additional research and data collection.

The strategies for broadening reach and impact profiled here
are:

Using the existing community infrastructure to provide
access and training in underserved communities through

Using the Existing Community Infrastructure to Provide Access
and Training in Underserved Communities

Libraries

Public libraries are the backbone of the traditional information
infrastructure. In the last decade or so, they have been refashioning
themselves, with major foundation support, to serve as hubs
of public computing, especially for people in underserved communities.
Thanks to extensive research and documentation, library-based
computer programs can inform public computing activities in
other settings as well. Libraries are an important and familiar
venue for public access computing, especially for people without
Internet access at home. They are the third most common place
for Internet access for children, after home and school, and
the most common access point for low-income and African American
children (Kaiser
Family Foundation, 2004). Twenty-eight percent of children
with disabilities go online from a library, compared to 17
percent of children without disabilities (Kaiser
Family Foundation, 2004). Ten percent of all Internet users—14
million Americans—regularly use library computers, which
are often the only form of access for low-income users (Bill
and Melinda Gates Foundation, n.d.).

Until recently, the potential of libraries as public computing sites was largely unrealized.
In 1996, only 28 percent provided public access computers; then, a combination of initiatives
raised the proportion to 95 percent by 2003 (National Commission on Libraries, cited in Bill
and Melinda Gates Foundation, n.d.). In the same year, the “E-rate” (Schools and
Libraries Universal Service Fund) created a $2.25 billion annual fund for discounts on connection
costs for schools and libraries. Starting in 1997, the Bill and Melinda Gates Foundation committed
$250 million to the U.S. Libraries Program, a new initiative to support public access computing
in libraries and to provide librarians with technical assistance training—“the largest
gift to U.S. public libraries since that of Andrew Carnegie” (Gordon,
Gordon, Moore, et al., 2003). The program is for libraries in areas with at least a 10-percent
poverty rate. By the end of 2003, it had installed about 40,000 computers and trained librarians
in about 10,000 communities, in every state and the District of Columbia. Because of these initiatives,
few sectors compare to libraries in “going to scale” to bridge the digital divide.
A Gates Foundation report states, “Today, if you can reach a public library, you can reach
the Internet” (Bill and Melinda Gates Foundation,
n.d.).

The Gates Foundation supported a 5-year independent evaluation
by the Public Access Computing Center (PACC) of the University
of Washington. The report, Toward Equality of Access,
synthesizes the evaluation research and multiple other data
sources in a rich overview of the history, status, and prospects
for public computing in libraries (Bill
and Melinda Gates Foundation, n.d.). These findings have
significance beyond libraries. For example, one PACC study
found that youth (who use an average of 4.2 locations for computer
and Internet use) “often find themselves as educators
when it comes to computer and Internet use”; 80 percent
have experience of this kind with adults (Public
Access Computing Center, 2003). Study director Andrew Gordon
also reports that library patrons use 31 percent of their Internet
access to learn about a medical problem (Gordon
et al., 2003).

The picture is not perfect, to be sure. Forty percent of libraries
have no technical training for staff (Public
Access Computing Center, 2004). Library computer users
often encounter long lines and limited technical assistance;
they may not live close to a library; and all libraries have
limited hours. Although libraries have gone to great lengths
to accommodate patrons who speak languages other than English,
these users are still at a disadvantage because of the limited
availability of content in their native languages.

Neither are the gains made to date assured, given local library
funding cuts, threats to the E-rate, aging equipment, and the
growing demand on limited library staffs. PACC research found
that 22 percent of libraries report having difficulty sustaining
their public access computing programs. It identified keeping
libraries open, retaining Internet connectivity, and increasing
library staff training as the three major challenges facing
public libraries (Public Access Computing
Center, 2004). The Gates Foundation has committed an additional
$17 million in challenge grants to help libraries sustain their
public access computing programs over the long term. Public
libraries join other sectors in having to focus on sustaining
the gains made to date, even as they seek ways to expand the
reach of their programs.

Community Technology and Community-Based Organizations

Nearly everyone comes to computers and Internet use armed
with some form of training or technical assistance, formal
or informal, often acquired in a supportive social environment.
These factors are typically available to middle- and upper-class
Americans through their jobs and educational opportunities.
Community-based technology programs are designed for low-income
adults and youth who either have no other means of access or
prefer the supportive learning environment they find there.

Community technology centers are a major vehicle for the technology
access programs of Federal agencies (particularly nonhealth
agencies such as the U.S. Department of Education), community-based
organizations, other nonprofit organizations, foundations,
and the telecommunications industry. These programs take many
forms and operate across a continuum of community-based and
home-based use, with different organizations and programs working
in different domains. The points of entry include low-cost
housing, libraries, healthcare facilities, community organizations,
and schools.

The typical community technology program offers a combination
of open access to computers and structured curricula, classes,
and technical assistance to help participants develop their
technology skills. The majority of local sponsoring organizations
has community development missions and uses technology as a
tool to help constituents advance their educations, employability,
and job access.

Diversity of funding streams and sponsorship, fluctuations
in organizational status, and other factors make it difficult
if not impossible to estimate reliably the number of community
technology programs in the United States. In general, this
study found that the available data are spotty and based on
either small programs or large surveys with low response rates.

A few somewhat impressionistic numbers, however, may give
some sense of scale. In 2005, the national organization of
community technology centers, CTCNet, had 1,200 paying organizational
members, a small proportion of the total number of organizations.
(A Chicago Web site lists 120 such centers in that city alone.)
Extrapolating from her previous research on public computing
in Toledo, researcher Kate Williams estimated between 88,000
and 144,000 public access computing sites in the United States,
including Government, library, commercial, and nonprofit sites
(Williams and Alkalimat, 2002).

Community technology centers are a subset of public access
computing that CompuMentor estimates at 33,000 to 56,000 centers.
A CompuMentor survey found that about 97 percent of these centers
serve low-income populations, 85 percent serve communities
of color, and 75 percent serve non-English speakers and people
with limited English proficiency (Hoffman,
2003). Using the average of CompuMentor’s estimate
(44,500 centers), a rough but conservative “guesstimate’”
of the number of people reached produces a total of 1,335,000
people.1 If each of these individuals
reaches two to three others in their “zone of influence”
posited by Manhattan Research, it is reasonable to project
that more than 3.3 million people a year use online resources
at community technology centers.

Community technology experts and programs have broad experience
in facilitating meaningful access and supplying multiple links
to community life. They have created trusted service infrastructures,
or use preexisting ones, and have demonstrated viable strategies
for working with diverse social groups. They specialize in
creating the congenial interpersonal context that diffusion
of innovation theory says is important for the adoption of
innovations (Rogers and Scott, 1997).
Some participants become “infomediaries” for friends,
relatives, and neighbors.

As an example of these synergies, One Economy Corporation
created an innovative training program that prepares young
people age 14 to 19 to serve as “Digital Connectors”
in their communities. Through this program, to date, 500 youth
have delivered more than 10,000 hours of service to approximately
3,000 families across 11 cities (S. Brachle, personal communication,
January 2006). The Learning Centers of SeniorNet (www.seniornet.org),
which serve another underserved and underconnected group, use
a peer training model for adults age 50 and older. Learning
Centers around the United States are managed primarily by senior
volunteers, with classes taught and coached by volunteer instructors.

Community technology is included as an example of a dissemination
strategy because those working in this field target and have
expertise in working with the low-income communities that are
at greatest risk of poor health and health care and most disconnected
from services. These programs are important for public health
because they represent an access point through which digital
health resources can be extended to the communities likely
to experience health disparities. Community technology programs
have demonstrated success promoting personal and community
economic development, and they can connect the same participants
to personal health management resources. At a minimum, their
content and dissemination models, research, and conceptual
work can inform the development of e-health tools for these
groups; at best, they themselves can serve as partners in e-health
dissemination strategies.2 In
addition, these programs model participatory approaches and
principles from which others interested in involving consumers
can learn a great deal.

In general, the present study found that the public health
and community technology fields seem to be at complementary
stages with respect to potential partnerships. Having laid
the groundwork in community capacities, the community technology
network is expressing interest in broader uses of technology
to improve their constituents’ lives. Public health programs
are searching for new and better ways to reach underserved
populations with health promotion and disease prevention tools.
Community technology programs have been honing the approaches
public health programs need to bridge gaps caused not only
by lack of technology but also by economic, cultural, and political
factors. For example, community technology consultant Dr. Randal
Pinkett of Building Community Technology Partners reports that
after the constituents in his Roxbury, Massachusetts, project
developed basic computer and Internet skills, they expressed
an interest in the health uses of the technology for the second
phase of the project (Pinkett, 2002).

Further research is needed to create a comprehensive, reliable
national picture of community-based access in relation to other
forms of access, provide baseline data on the important issue
of broadband deployment, and determine what is needed to strengthen
community capacities to support personal health management.
However, informants in this field express the view that there
are enough pockets of information to start developing strategies
for expanding e-health tool access in underserved communities
(Conference Call on e-Health and Community
Technology Access, May 18, 2004; see Appendix
2). Given the appropriate tools and capacity-building,
community technology programs that embrace health applications
as a priority service might play a crucial role in widening
the access of underserved audiences to useful tools for enhancing
their health.

Implementing a Statewide Strategy Involving Multiple Partners

Many states have notable programs to broaden technology access
to improve citizens’ lives. Through One Economy’s
Bring IT Home public policy campaign, for example, 38 states
have amended their housing finance policies to provide incentives
or mandates to developers that support the penetration of broadband
in affordable housing.3 The
California experience models a statewide community technology
strategy with several components. The strategic partners and
participants come from national and state-based business, academic,
philanthropic, public interest, and advocacy organizations,
with the state’s large and diverse population groups
playing a strong role.

At the center is Computers in Our Future (CIOF, www.CIOF.org),
a seminal program that helped create a scaffolding, if not
an infrastructure, for technology access programs across the
state. It was conceived and funded by the California Wellness
Foundation to demonstrate the impact of increased technology
access on education and employment opportunities for young
people in low-income communities. The Wellness Foundation reasoned
that education, employment, and economic development are preconditions
of health and thus an appropriate investment for a foundation
with a wellness mission. In 1997, the Foundation awarded 4-year
grants totaling $7.5 million to rural and urban community-based
organizations around the state for the establishment of 11
community technology centers.

CIOF is somewhat unusual, and exemplary, among community-based
organizations in the thoroughness of its data on the project.
By the end of the grant period, the centers had trained 22,500
people in computer use, half of them young people (Fowells
and Lazarus, 2001). They successfully reached priority
audiences: roughly 80 percent of users are members of racial
and ethnic minority groups. The project also produced a set
of workable models for introducing technology and its uses
to disadvantaged communities. The models involved open access
to technology, training and skill building, linkages to employment
resources, community resource functions, and a means of expression
for community technology advocacy. Although access to health
information was not emphasized, many centers provided it.

Nine of the 11 community technology centers established by
CIOF still exist. They share the landscape with other community
technology endeavors, some of which started around the same
time as CIOF and others of which resulted from it. Money from
telecommunications companies is a common funding source for
such programs, often mandated as a condition of mergers or
other regulatory actions.

In California, an important grantmaking institution is the
Community Technology Foundation of California (CTFC), which
was created in 1998 by 134 community organizations and Pacific
Bell (now part of SBC Communications). CTFC focuses on collaborative
efforts “in California’s low-income, minority,
limited-English-speaking, seniors, immigrant, and disability
communities” (www.ZeroDivide.org).
It funds access programs for a number of target populations—for
example, the San Francisco-based Latino Issues Forum (www.lif.org),
which has programs on health, technology access, civic participation,
and sustainable development.

The Community Technology Policy Council, another CTFC grantee,
produced a detailed report on access among Asian Americans
and Pacific Islanders, its constituency—another well-documented
“pocket of information” about community access
and use (Community Technology Policy
Council, 2004). CTFC also sponsors the Access Fund, which
partners with the national Alliance for Technology Access to
help organizations eliminate barriers faced by people with
disabilities through program assessment, consulting services,
technical assistance, and grants.

One focus in California, as elsewhere, is on sustaining the
gains made in recent years. Linda Fowells of Community Partners,
a Los Angeles-based nonprofit organization active in this area,
regards advocacy activities as critically important. She says,
“Policy work is the cutting edge of community technology
today because that’s what will assure sustainability”
(L. Fowells, personal communication, March 2004).

Virtually all of the aforementioned state groups are part
of the California Community Technology Policy Group, which
leverages policy information, training, grassroots advocacy,
and lobbying to push for favorable state legislation and regulation.
Such efforts have been markedly successful over the last decade.
For example, California was the first state to have a set-aside
fund for broad digital divide projects. The California Teleconnect
Fund, which predates and is broader than the Federal E-rate,
makes Internet connection available at half the market rate
to schools, libraries, community-based organizations, and healthcare
organizations.

In the health sector, the Northern Sierra Rural Health Network
demonstrates innovative uses of technology and public policy
to promote personal health management in a rural area. Headquartered
in Nevada City and funded by the U.S. Department of Agriculture’s
Universal Service Fund, it coordinates a telemedicine network
that it helped develop in its region. Working with two Stanford
University clinician/researchers, the Network piloted a support
group for women with breast cancer in two isolated communities,
using videoconferencing facilities available in the local medical
centers. The group is modeled on Internet support groups, which
are not an option in that region because of the lack of high-speed
Internet connection.

Reaching Out to Target Audiences

This section profiles three outreach programs—two sponsored
by Federal agencies and one sponsored by a national nonprofit
organization—that combine targeted resources, participatory
models, and alliances with community-based organizations.

The National Library of Medicine (NLM) is charged with managing
and disseminating scientific health information. It manages
scores of Web sites for health professionals and, increasingly,
consumers and collaborates with a network of regional libraries.
A decision by NLM to join more forcefully in the effort to
eliminate health disparities has led in recent years to a significant
expansion in its approach to disseminating health information
for underserved groups.

NLM intensified its outreach to American Indians in 1997 in
an initiative called the Tribal Connections Project. The project,
whose ultimate aim is to help underserved Indian communities
connect with broad-based health information, has much in common
with the community technology programs described above.

Specialized content development is part of the story. NLM
sponsors three Web sites for American Indians and Alaska Natives.
TribalConnections.org,
which initially focused on serving the indigenous people of
the Pacific Northwest and Alaska, began as a portal to health
information sites of interest to healthcare providers and consumers.
Recently, it has evolved into also providing its own content,
using Native American writers to pen health-related articles
that combine Western and Native approaches to healing and healthy
living. TribalConnections.org
also disseminates the articles to Native American publications
across the United States.

Having set the goal of expanding its services to Native Americans,
an underserved community, NLM invested significant resources
in a broad, multifaceted program. The program included assessing
local needs and building awareness of the Internet, forging
new partnerships with and between the participating American
Indian reservations and Alaska Native villages and other organizations,
improving the information technology infrastructure and Internet
connectivity at 15 of 16 sites, and conducting training sessions
with several hundred tribal participants across 13 sites.

The organizers report that “the project demonstrated
the key role of tribal community involvement and empowerment
and contributed to development of an outreach evaluation field
manual and the evolving concept of community-based outreach”
(Wood, Sahali, Press, et
al., 2003). Project director Fred Wood adds that NLM learned
from its tribal work that “the old ways of disseminating
health information do not work for reaching underserved population
groups. What is needed is a robust multidimensional approach
to outreach” (F. Wood, personal communication, October
7, 2004). NLM is now using community-based outreach strategies
in many communities throughout the country, as reflected in
its National Library of Medicine Strategic Plan for Addressing
Health Disparities 2004-2008 (www.nlm.nih.gov/pubs/plan/nlm_health_disp_2004_2008.html).
NLM convened stakeholders in a December 2004 symposium to review
the plan for community-based health information outreach (http://medstat.med.utah.edu).

One Economy Corporation (www.one-economy.com),
a national nonprofit organization based in Washington, DC,
uses targeted content as part of a broader strategy to promote
meaningful technology access. It identifies the 12 million
people living in Government-supported affordable housing and
the 5 million living in non-Government-supported affordable
housing, as its primary and secondary markets, respectively.
The organization makes the “equity case” for widening
access and promotes a strong governmental role. For example,
it leads a national advocacy effort, Bring IT (Information
Technology) Home, aimed at state policy. (Some of its accomplishments
are described above.) In addition, One Economy makes the economic
case for widening access, pointing out that the 27 million
people in affordable housing represent $250 billion in purchasing
power. In its words, it seeks to demonstrate “how technology
can enhance the interaction between affordable housing residents,
nonprofit organizations, local government, and the private
sector” (One Economy Corporation,
2004).

One Economy particularly stresses the need of low-income users
for local information, noting that “online content has
been primarily designed for Internet users who have discretionary
money to spend, that is, a highly educated audience that reads
at average or advanced literacy levels” (One
Economy Corporation, 2004, p. 26). In 2001, One Economy
launched the Beehive (www.thebeehive.org),
a bilingual Web site providing localized “self-help content,”
including considerable health information, “in languages
and at a literacy level that speak to low-income people”
(One Economy
Corporation, 2004, p. 27). Its literature describes the
Beehive as “going significantly beyond the issue of access
to technology and addressing the content and culture change
it will take to achieve economic outcomes.”

To date, localized Beehive sites have been developed for 26
cities and 1 state (Kentucky). Nationally, the Beehive serves
more than 300,000 users every month. One Economy stresses home-based,
rather than community-based, technology access because of the
greater convenience and privacy of operating from home. In
what might be called the apotheosis of its approach, 200 new
units of affordable housing in the South Bronx were outfitted
with a centralized Internet connection and household wireless
access capabilities in 2004. The cost of Internet access is
built into the rent for these units, and targeted content is
available from the Beehive.

Targeted content development also proved essential in serving
the inner-city populations of a National Cancer Institute (NCI)
program in New York City. The Digital Divide Program (DDP)
was NCI’s first effort explicitly aimed at finding ways
to get digital cancer information to people on the other side
of this divide. NCI was motivated by the knowledge that ethnic
minority, low-income, and less educated populations bear a
disproportionate cancer burden and have limited access to electronic
health information.

The purpose of DDP research was to find out more about various
groups’ interest in and use of cancer information tools
to inform future program design. In September 2000, NCI awarded
roughly $1 million (total) to four programs, all joint efforts
between the Cancer Information Service (CIS) and regional organizations,
to test strategies to increase cancer communications in underserved
communities. Collectively, the four DDPs addressed all components
of meaningful access: appropriate content, equipment provision,
Internet access, and skill development and support. Former
NCI Program Director Gary Kreps writes that the programs modeled
“provocative new community strategies for providing underserved
groups of people with access to relevant computer-based information
about cancer” (Kreps, 2002).

In New York City, the DDP of the Memorial Sloan-Kettering
Cancer Center CIS collaborated with the Verizon Education and
Technology Center in Harlem and other community organizations
to train program participants. Among other benefits, this helped
to raise awareness of the location of public computing access
points. Perhaps the most significant feature of the Sloan-Kettering
project was its development of an innovative information resource
for constituents that combines health information content and
practical assistance in the use of online resources.

Concluding that the voluminous cancer information available
on the national CIS site was too complex and overwhelming for
its target audience, project managers developed a special user-friendly,
bilingual Web site for their program. CancerInfoNet.org
presents information about cancer in an organized and easy-to-read
format and provides links to a few selected Government-approved
sites for each type of cancer. It also offers Web-based instruction
and practice opportunities for using the Internet, along with
tips for evaluating Web content. Fourteen other CIS programs
around the country are now using CancerInfoNet.org.

Supporting Reseach and Development Involving Diverse Audiences

The Federal and foundation programs described in this section
support the translation of research findings into evidence-based
e-health tools for consumers, patients, caregivers, and, in
some cases, healthcare providers. They are included here because
of their emphasis on developing techniques for reaching diverse
and underserved audiences.

Among Federal agencies, NCI has played a leading role in furthering
health communication in general and e-health tools in particular.
In one of its several consumer-oriented initiatives, NCI uses
Small Business Innovation Research (SBIR) grants to help develop
evidence-based, commercially viable e-health applications for
diverse and underserved audiences.4
The Institute has invested heavily in translating cancer research
findings into products that use media technology to reduce
cancer risks, provide treatment options, and address the needs
of cancer survivors. The SBIR program has a number of notable
characteristics, not the least of which is that it is one of
the largest programs funding the development and dissemination
of evidence-based e-health tools. It uses the rigorous National
Institutes of Health (NIH) scientific review process, with
peer review panels composed of academic experts and small business
owners with experience in public health, communications, or
media technology.

SBIR funds eight categories of research, seven of which are
for consumers, patients, or caregivers. Among other things,
the research projects facilitate changing behaviors associated
with cancer risk; support family and individual decisionmaking
related to cancer genetics; develop communication techniques
for diverse populations; provide interactive programs to help
with survivorship and quality-of-life issues; and develop public
access systems for cancer education, information, prevention,
screening, and assessment.

NCI’s SBIR program places strong emphasis on serving
high-risk and diverse populations. A number of the tools it
has funded use community-based sites to enable access for individuals
without home computers—for example, a public access multimedia
kiosk with bilingual information on breast cancer for Spanish-speaking
women. Grant guidelines stipulate a developmental process that
includes end-user participation (through focus groups) in product
feasibility testing, design, and evaluation. The guidelines
also require two rounds of usability testing, one independently
conducted and one using NCI’s Usability Lab, with the
costs covered by the grant. To date, approximately 75 e-health
tools have been developed, tested for usability, and evaluated
as to efficacy through NCI’s SBIR program and either
are now or soon will be in the commercialization stage.

Although decidedly closer to “bedside” than to
“bench” from the outset, the SBIR program still
has limitations related to sustainability, dissemination, and
monitoring effectiveness over the long term. As a partial effort
to address this limitation, grantees since 2003 have been required
to devise a means of tracking sales and purchaser demographics.
A closely related program, the NCI Centers for Excellence in
Cancer Communications research initiative, is another major
Federal investment in the role of communications in narrowing
the gap between discovery and application and in reducing health
disparities.

The Robert Wood Johnson Foundation (RWJF) and NCI cosponsored
a research dialogue on online behavior change and disease management
in August 2001 (National
Cancer Institute and Robert Wood Johnson Foundation, 2001).
The principles articulated by meeting participants are the
standard ones put forward for communicating with diverse audiences,
including tailoring content and assuring usability and appropriate
technology access. Participants recommended that forthcoming
research identify the salient characteristics—such as
culture, literacy, trust of e-health information, and Internet
use—that influence interactive health communication for
different population groups. These are the same research issues
highlighted in the Institute of Medicine report, Speaking
of Health, which stresses the need for research to determine,
first, whether “paying attention to heterogeneity matters,”
and second, if it does, which health communication interventions
are most effective (IOM,
2002).

These principles helped shape RWJF’s Health e-Technologies
Initiative (www.hetinitiative.org/),
which began in 2003. The Foundation committed $10.3 million
to support research to advance the discovery of scientific
knowledge regarding the effectiveness of interactive applications
for health behavior change and chronic disease management.
The first round of awards, funded through a 2002 call for proposals,
included 8 Outcome Evaluation Awards that evaluate specific
consumer e-health tools and 10 Methodology and Design Awards,
4 of which relate to consumer e-health tools. The second round
of grants, through a 2004 call for proposals, funded eight
additional awards of up to $400,000 to study consumer-facing
Web portals. One goal of Health e-Technologies is finding out
“whether or not these applications improve processes
and outcomes of care for culturally diverse groups of patients/consumers.”

Summary

This chapter describes cases and identifies new constituencies
for the use of technology and e-health tools in diverse and
underserved communities. The strategies involved are:

Using the existing community infrastructure to provide
training and open access in underserved communities through

Libraries

Community technology and community-based organizations

Implementing a statewide strategy involving multiple
partners

Reaching out to target audiences

Supporting research and development involving diverse
audiences

These projects illustrate, to varying degrees, principles
and attributes that will be important in future initiatives
to widen reach and impact. First, all employ comprehensive
approaches to achieving meaningful access. Second, they involve
a wide number of partners and stakeholders, as demonstrated
particularly well in the California example. Third, they use
participatory approaches that engage consumers not just as
targets and recipients but also as designers of content and
services. They are not just for but also by and with diverse
communities. The community technology and NLM examples are
the most explicit about this approach. Fourth, they offer sustained,
continuous services at the community level. Library programs
exemplify this attribute, although, as noted, their longevity
is not assured. Finally, all these projects leverage significant
resource commitments from a range of sponsors, including Federal
agencies, industry, and foundations, in each case serving as
important vehicles for their sponsors’ missions and program
objectives.

1"Guesstimate” based on 44,500 centers with 100
users per center per year, 30 percent of whom seek health information.

4The
small business grants program, established in 1982, combines
two funding mechanisms—Small Business Innovation Research
(SBIR) and Small Business Technology Transfer (STTR)—both
of which are designed to involve small businesses in stimulating
technological innovation. Eleven Federal agencies and several
NIH Institutes use the mechanism. See http://grants.nih.gov/grants/funding/sbir.htm
for information on NIH’s small business program.